Failure to Notify Provider of Abnormal BP Readings The facility did not notify the provider when a resident’s BP was outside ordered parameters. One resident with HTN, stroke history, and repeated falls had many BP readings above the ordered limits over several months, with no documentation of provider notification. Two other residents with HTN also had BP readings below ordered limits, including low readings during med pass, and their records likewise showed no evidence that the provider was notified.
Failure to provide ordered bowel care interventions for a resident with constipation and severe cognitive impairment. The resident had PRN bowel meds ordered, and the facility's bowel management guideline required escalating interventions when no BM occurred, but the bowel task record and MAR showed no bowel interventions were given during four consecutive days without a BM. An LPN and the COD confirmed the resident did not receive bowel management interventions during that period.
A facility failed to complete glucometer QC testing when new test strip bottles were opened for two residents, and staff confirmed the required control solution entries were missing from the log. The facility also failed to follow PICC dressing-change technique for a resident, with the RN using nonsterile handling steps and contaminating concerns during the procedure. In addition, the RN did not flush both PICC lumens as ordered and the resident’s MAR order for IV Unasyn lacked key administration details such as the infusion amount, duration, and rate.
The facility failed to carry out multiple provider orders for a resident with CKD, pulmonary issues, and an indwelling catheter, including ordered BMP testing and IV LR, and the resident later had a critically high creatinine and was sent to the ER. The facility also missed or delayed routine labs for other residents, including CBC, CMP, TSH, Vitamin D, and UA testing, with some orders not completed until days or months later.
A resident with a CVA-related hemiplegia sustained a fall with left ankle pain and later was found to have an ankle fracture, but the record did not show a follow-up injury assessment, timely x-ray result retrieval, or an orthopedic appt being scheduled. In addition, two residents with significant mobility and continence needs had missing weekly skin/wound observations over multiple weeks, despite staff and policy stating these assessments were to be completed weekly.
Failure to monitor bowel movements and blood glucose. A resident with Alzheimer’s disease and severe cognitive impairment had repeated days with no bowel movement charting and did not receive the ordered bowel protocol medications despite standing bowel orders. Another resident with diabetes had ordered BID blood sugar checks, but evening glucose readings were not documented for several days, and the DON confirmed the missing documentation and that the MAR had no place to record the reading.
Failure to Follow Orders for Urinalysis, Oxygen Notifications, and Daily Weights: The facility did not follow a practitioner order for a UA/C&S for one resident with a suprapubic catheter and cognitive impairment, did not notify the PCP for another resident’s repeated O2 sats below 90% while on O2, and did not obtain ordered daily weights or notify the PCP of 5-lb-or-greater weight gains for a third resident. The DON and IP confirmed the missed orders and missing notifications.
A resident who was incontinent and required substantial to maximal assistance with toileting hygiene had skin concerns documented on admission, including bruising, scabs, and redness in skin folds and the buttocks area. Although skilled observations, bathing, and incontinence care occurred during the stay, none of the skilled observation notes documented skin checks, and a later-created skin/wound form noted the resident refused a skin assessment. The DON confirmed there was no documentation of skin being observed or assessed during the stay.
Failure to Follow Bowel Elimination Protocol: Two residents with bowel management needs did not receive the facility’s required constipation interventions when bowel movements were absent. One resident with constipation, ulcerative colitis, and severe cognitive impairment had repeated gaps in bowel movement documentation, and staff confirmed the bowel protocol was not started on time. Another resident with stroke-related hemiplegia, dementia, and opioid use for pain had no bowel movements over several days, yet the MAR showed no documented administration of the PRN constipation medication, and an MA confirmed the resident should have received bowel intervention.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
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